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To review on from subsequent updated work of chapter 1
Sleep problems can be due to various factors. The sleep disturbance or disorder is
a condition that frequently impacts the ability to get enough quality sleep (Cho et. al.,
2017). Lack of enough sleep leads to attention deficits, poor memory, and generally
slows down the reaction times (Ohayon and Caulet, 1995). Sleep disturbances can be
ranked from least to the most severe problem as difficulty falling asleep, short duration of
sleep, poor quality of sleep, light sleeper, and insomnia (citation). Firstly, for people
experiencing difficulty falling asleep, which sometimes refers to sleep-onset insomnia,
they cannot give their mind a chance to unwind (citation). Therefore, the body is not
prepared for rest at what is viewed as a typical time to rest. Secondly, for people
encountering short duration of sleep, may experience postponed rest stage issue, and jet
lag (citation). Thirdly, for people experiencing poor quality of sleep, they nod off
frequently (citation). Fourthly, people can experience a more severe problem such as light
sleeper which might happen in individuals who utilize certain substances for example
liquor or take certain medications to induce sleep (citation).
Worst Consequence of Sleep Disturbances: Insomnia
Insomnia is define as (citation)
Insomnia must be clinically diagnosed by a doctor (citation). They include but are not
limited to . .
Insomnia and disturbed sleep are prevalent among the aged population. It has
found that up to seven in ten of all adults 65 years and above have insomnia symptoms
(Zhang et. al., 2016). Another study by Zhang et. al. (2016) states that one in four of
adults suffer from one at least one sleep disorder according to a survey carried out by the
Korean Sleep Research Society in 2006. Of all the type of sleep disturbances, insomnia is
the most severe which is characterized by the difficulty of sleeping (Montplaisir, 2000).
IT IS MORE SERVE THAN the other types (the impact effect of insomnia. It is very
disturbing (impact). (Citation)
So some resort to pharmacological interventions are often used to treat sleep
disorders, However, they have numerous side effects and many are not recommended for
prolonged use. They cause such side effects as addictions, confusion, and drowsiness
during the day among others. Sleep disorders and disturbances are prevalent among those
aged 65 years or older because of the positive correlation between sleep disorders and
health conditions like frailty and fall (Zhang et. al., 2016).
At least one third of community-dwelling older adults (> 65 years) sustained a fall
in a year in their living environment (Lytle et. al., 2014). A fall is an event which results
in a person coming to rest inadvertently on the ground, floor or other lower level (Lillehei
et. al., 2015). At an individual level, falls can result in detrimental effects such as
prolonged recovery from physical injuries, hospitalization, loss of independence and
reduced quality of life (Lillehei et. al., 2015). Falls can cause emotional stress to
caregivers such as a constant worry of the possibility of their care recipient falling again
(Hwang & Shin, 2015). A systematic review of the cost of treatment per fall victim of
community populations in developed countries found that the estimated treatment costs
between 2,044 and 42,840 USD per year reflected significant healthcare costs (Ma et. al.,
2017). The authors suggested that more severe falls are likely to result in higher
healthcare costs than falls that are less severe, so it is important to prevent severe falls.
The Association between fall and sleep disturbances
(I WANT FIGURE of Community dwelling and here is strictly the association between
fall and sleep disturbances) (Citation)
Based on this discussion, the above research suggests that there is a possible relationship
between sleep disorders and the risk of falls among the elderly. A combination of these
effects greatly increases the risk of falls, especially among older adults.
According to the centre for disease control (CDC) as shown in (Figure. 1), there is 35.2
percent adults has faced insomnia (Ades TB, 2009). Drugs are not sustainable and in the
last two decades, healthcare researcher have been exploring non-pharmacological
treatment with minimal side effects like music therapy and aromatherapy. (How many
decades used in aromatherapy in medical research? (Citation)
Figure. 1: Insomnia Figure
AROMATHERAPY (need help with paraphrasing as its taken word for word)
Aromatherapy has recently gained traction as an alternative therapy. It perceives
humans as holistic beings and focuses on their balance and harmony as components
of nature. Aromatherapy is a type of complementary alternative treatment that
promotes physical, emotional, and psychological health by using the therapeutic
elements of essential oils found in the flowers and leaves of various natural plants,
stems, and roots (Citation). Aromatherapy uses aroma essential oils to achieve
balance in the patient by calming the mind, body, and spirit (Citation). A relatively
effective and safe treatment that does not accumulate in the body, but is discharged
from the through the respiratory system, liver, and kidneys (Citation).
Aromatherapy is a noninvasive treatment that directly affects the brain, and
individuals can self-administer the treatment regardless of time or place (Citation).
Aromatherapy is cost-effective, convenient, and accessible for addressing sleep
issues can aid in decreasing the associated wide ranging health effects of lack of
sleep (Citation). In addition, it provide antibacterial, wound-healing, immune
enhancing, antidepressant, calming curative effects, alleviates stress, and increases
sleep quality. (Citation)
How aromatherapy induce or promote sleep (Citation)
Scope of the Study
The thesis first seeks to offer a clear understanding of the relationship between
sleep disturbances and fall, the efficacy of aromatherapy in promoting sleep of the
problem, which is the high prevalence of insomnia among the elderly. Statistics are
offered in regards to the incidence rates of falls and the effect of poor sleep quality on
these rates. The study also evaluates different methods in which aromatherapy treatment
can be used to assist in the improvement of sleep quantity and quality. The study focuses
on the use of aromatherapy in treating sleep disorders and reduces fall. These health
benefits are important to mention because sleep disorders among the elderly have been
associated with poor health conditions.
Literature Review Data Selection
The search strategy facilitated identification of all available research data relevant to the
particular research question The effect of aromatherapy in reducing sleep disturbances
and falls among the older adults in home. Subsequently, A short description on PICO
was described in terms of Participants, Interventions, Comparisons, Outcomes (PICO) as
shown in (Figure. 2).
Figure. 2: PICO Framework
Question Type: Prevention
Population, Patient, Problem Older adults with sleep disturbances
Sleep medicine or no intervention
Sleep quality and incidence of fall associated with sleep disturbances
A systematic computerised literature search was conducted in multiple
bibliographic databases (CINAHL, PubMed, and Science Direct). Depending on the
selected database, advanced search and free text was combined with the Boolean
operators AND/OR to build a search strategy. Search terms were divided into two sets,
namely A and B to widen the search accordingly as shown in (Figure. 3). The words
searched included the following:
Set A: aromatherapy,essential oil,aromatherapy, and improved sleep,
increased sleep, and improving sleep.
Set B: sleep quality, and falls, fall risk, fall prevention, prevention,
and geriatrics, older adults, elderly, aged, older, elder, and
Figure. 3: Search Strategy
Search carried out in CINAHL, PubMed and Science Direct. Date of search 18/01/2018
Aromatherapy OR essential oils OR aroma therapy
Improved Sleep OR increased sleep OR improving sleep
Falls OR fall risk OR fall prevention OR prevention
Geriatrics OR older adults OR elderly OR aged OR older OR elder OR elderly
1 AND 2
1 AND 3
1 AND 4
1 AND 5
2 AND 3
2 AND 4
2 AND 5
3 AND 4
3 AND 5
4 AND 5
3 AND 4 AND 5
6 AND 16
Yellow – (Keywords for Set A)
Green – (Keywords for Set B)
Blue – (Tabulated between Set A and B)
Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA)
as shown in (Figure. 4) were done to narrow down to the most relevant sources for the
literature review, restricting the search to articles published from database inception
between 2012 and 2017 in English language, academic journals, full text and in subject
major. For example, when searching for relevant articles in relation to set A and B, the
filters of subject major (i.e. essential oil, treatment, health, sleep and sleep quality). Out
of 1061 studies identified in the databases, a selection of 990 studies was made. The total
number of studies excluded was 974, with 961 failing to qualify based on their titles and
abstracts, and 16 papers were discarded because the outcome of interest was irrelevant to
the thesis. This literature search finally included thirteen studies that met the search
Figure. 4. Flow diagram of study
CASP Tools and Evidence
The thirteen studies were then evaluated using Critical Appraisal Skills
Programme (CASP) for quality. The framework is composed of questions that allow for
an assessment of the published papers trustworthiness, relevance and results (Citation).
The responses yes, no, or cant tell are used to answer and judge each question.
Subsequently, nine of the thirteen studies were chosen for review, reflecting a strong
influence of research. The CASP tool checklists are shown in (Appendix 2) and
summarized in an evidence finding tables as shown in (Appendix 1).
Hierarchy of Evidence
This research combined a number of studies the selection of which was based on
their relevance to the study and the integrity of the data contained as determined by an
evaluation of the methodologies used in both data collection and analysis. Randomized
controlled trials which are fourth in the hierarchy of evidence pyramid in (Figure. 5)
dominated the list of studies used. These were especially used as evidence of the effect of
aromatherapy on patients who suffer from various disorders. There were also three
systematic reviews (second level of the hierarchy), which consisted of data analyses of
various past studies to test set hypotheses. A qualitative research conducted on dementia
patients response to aromatherapy treatment was also used, as was a cohort study
investigating the incidence of falls among the Chinese elderly. Both of these studies are
represented in the second and third lowest levels of the hierarchy respectively.
Figure. 5: Hierarchy of Evidence Diagram
Reference: The Board of Regents of the University of Wisconsin System. (2017,
December 4). LibGuides: Evidence-Based Medicine: Acquire. Retrieved
The impact of sleep quality in relation to sleep disturbances
Lillehei et al (2015) conducted a randomized controlled trial and blind on both the
investigators and the participants. In their study, they focused specifically on the effect of
Lavender, which is one of the most commonly used therapeutic oils in aromatherapy, on
the enhancement of sleep quality. It aimed to investigate whether the quality of sleep of
the participants would change if lavender was introduced. The outcome of interest under
investigation were slept quality and sleep quantity. The National Sleep Foundation Diary
was used to record the daily sleep information by the participants (Lillehei et al, 2015).
This was used to complement the Fitbit One (I suspect it is surrogate marker?) tracking
device used to record sleep, which sometimes mis-recorded moments of wakeful nonmovement as sleep. The diary was to assist in the correction of this error. The Pittsburgh
Sleep Quality Index (PSQI) is this validated one? Explain PSQI with (Citation) recorded
sleep quality in seven component scores and was accompanied by the Patient-Reported
Outcomes Measurement Information System (PROMIS) form which records sleep
disturbance (Lillehei et al, 2015).
This study was conducted by Lillehei et al (2015) for five nights with all other
factors maintained constant except for the provision of a lavender patch to the
experimental group, and the lack of one in the control group. There was also a postintervention and two-week follow-up to evaluate whether and how long any effect that
was achieved lasted. Notably, the experimental group experienced significant sleep
quality changes as compared to the control group (PSQI <0.001, p=.01 and a PROMIS 0.007, p=.04.) for the lavender group and PSQI 0.06, p=.02 and a PROMIS 0.03, p=.03 for the control group (Lillehei et al, 2015). In addition, the study participants in the intervention arm also reported better sleep hygiene such as maintain a regular sleep schedule, avoid fluid intake before bed and food, caffeine, alcohol, and nicotine late in the day, create a good sleeping environment (e.g., wear ear plugs and a sleep mask), create a relaxing bedtime routine, and exercise regularly. (Need help with paraphrasing as copy word for word). However, the sleep quantities recorded presented no significant differences between the two groups. Angela Smith et al (2015) has assessed the effect of sleep hygienic and inhaled lavender aromatherapy on sleep issues. This paper has the aim to compare the inhaled lavender aromatherapy and sleep hygienic. The author recruited 79 study participants who self-reported sleep related outcome of interest. At postintervention, the group treated with lavender infusion reported better sleep hygiene and sleep quality. On the other hand, the sleep quantity did not differ between groups. Teng Ma et al (2017) has examined the sleep disturbance among the old Chinese population. The main aim of this paper is to assess the association between the sleep disorders and the old population. In this paper, the author has used the primary method of collecting data from 1726 individuals from the age of 70-87 years. The author has concluded that the poor sleep symptoms have consistently related with increased risk of falls in elderly. The above mentioned studies utilised different study design to evaluate the efficacy of aromatherapy. Though the designs were different, the results were positive. Thus, aromatherapy could possible be promising in the local older population. A short CRITICAL discussion of the above theme The relationship of sleep quality resulting to falls Ma et al (2017) have described the relationship between sleep quality and quantity and falls among the elderly is significant especially due to the severe consequences of falls, which often cause serious injury or death. The author aimed to establish this relationship using systematic review of data of 1726, 70-87-year old individuals. The outcome of interest was the number of falls in each calendar year. The nature of sleep was measured in terms of sleep disturbance, quality, efficiency (Ma et al, 2017). There was a positive correlation between frequent sleep disturbance and fall incidences. Shorter sleep duration were also associated with falls (Erin, et al., 2016). Zhang et al (2016), have investigated and described the relationship between sleep quality and falls, the author has come up with similar findings, but also found that the elderly women who were not experiencing the required quality and quantity of sleep were more predisposed to falls than the men were. The study carried out in Boston, Massachusetts involves the analysis of cross-sectional data of 954 participants. In this paper, interviews were conducted on the participants of these studies after a two year follow up. Sleep quality and quantity information to determine the levels of insomnia was collected to determine how exposed the participants were, and information of the number of falls that the participants had experienced over the past one year was also recorded (Zhang et al, 2016). Data associated with sleep disturbances such as lifestyle behavioral, gender, medical use, mental status, comorbidities, and medication were collected to for statistical adjustment to provide a more precise point estimate in the Poisson regression model. In the fitted Poisson regression model, older adults who were over 60 years old were independently associated to fall. This study also evaluated on the use of non-pharmacological interventions such as aromatherapy for insomnia, RESULT???? Yaung Zhang et al (2016) has elaborated the association between insomnia and falls in Boston Puerto Rican adults with the specific age and gender. This article has described that how age and gender create an impact on Puerto Ricans adults. The author has collected the data from 954 study participants. A short CRITICAL discussion of the above theme The effect of aromatherapy on sleep quality (this third and last theme need help on consolidating) Aromatherapy is used on human beings as it is an essential treatment for the improvement in the sleep quality and quantity. The duration for aromatherapy from 1-2 days to 4-8 weeks (Ericksen, 2000). In this time period, the effects of the disease are reduced to some extent. Eun Cho (2017) sought to determine whether aromatherapy had any positive effect on their sleep quality or stress levels. The objective of this paper is to examine those effects that can create a negative impact on the patients. Stress has physiological and psychological effects that create a negative impact on the treatment and recovery of patients. The author has used the non-randomized study carried out using two groups consisting of 32 participants each. To evaluate on the efficacy of aromatherapy, one of the groups was treated by lavender oil inhalation while the control group did not receive any aromatherapy treatment. The treatment involved breathing deeply from an aroma stone that had lavender oil in it and having it hung over the bed all night from 9 pm to 8 am. The control and experimental groups have shown the significant difference in the perceived stress and in the objective stress. However, it has not discussed the effect of stress on the sleep quantity (Hee, Lee, & Hur, 2017). In addition, sleep quality decreased sharply by 50% for the control group while it decreased by only 10% for the experimental group, indicating that the aromatherapy could have allowed the experimental group to have a better quality sleep. Aromatherapy treatment could, therefore, be used to improve sleep quality (Cho et al, 2017). Seo Yeon Choi and Kyungsook Park (2016) has assessed the effect of inhalation of aromatherapy on patients. Aromatherapy is one of the ways in which the overall health o ... Purchase answer to see full attachment
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